Yong Ji Sang, Dewire Jane, Barcelon Bernadette, Philips Binu, Catanzaro John, Nazarian Saman, Cheng Alan, Spragg David, Tandri Harikrishna, Bansal Sandeep, Ashikaga Hiroshi, Rickard Jack, Kolandaivelu Aravindan, Sinha Sunil, Marine Joseph E, Calkins Hugh, Berger Ronald
Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
J Cardiovasc Electrophysiol. 2013 Oct;24(10):1086-91. doi: 10.1111/jce.12210. Epub 2013 Jul 19.
Phrenic nerve injury (PNI) is a well-known, although uncommon, complication of pulmonary vein isolation (PVI) using radiofrequency energy. Currently, there is no consensus about how to avoid or minimize this injury. The purpose of this study was to determine how often the phrenic nerve, as identified using a high-output pacing, lies along the ablation trajectory of a wide-area circumferential lesion set. We also sought to determine if PVI can be achieved without phrenic nerve injury by modifying the ablation lesion set so as to avoid those areas where phrenic nerve capture (PNC) is observed.
We prospectively enrolled 100 consecutive patients (age 61.7 ± 9.2 years old, 75 men) who underwent RF PVI using a wide-area circumferential ablation approach. A high-output (20 mA at 2 milliseconds) endocardial pacing protocol was performed around the right pulmonary veins and the carina where a usual ablation lesion set would be made. A total of 30% of patients had PNC and required modification of ablation lines. In the group of patients with PNC, the carina was the most common site of capture (85%) followed by anterior right superior pulmonary vein (RSPV) (70%) and anterior right inferior pulmonary vein (RIPV) (30%). A total of 25% of PNC group had capture in all 3 (RSPV, RIPV, and carina) regions. There was no difference in the clinical characteristics between the groups with and without PNC. RF PVI caused no PNI in either group.
High output pacing around the right pulmonary veins and the carina reveals that the phrenic nerve lies along a wide-area circumferential ablation trajectory in 30% of patients. Modification of ablation lines to avoid these sites may prevent phrenic nerve injury during RF PVI.
膈神经损伤（PNI）是使用射频能量进行肺静脉隔离（PVI）时一种众所周知但并不常见的并发症。目前，对于如何避免或最小化这种损伤尚无共识。本研究的目的是确定使用高输出起搏识别出的膈神经沿大面积环状病变集的消融轨迹分布的频率。我们还试图确定通过修改消融病变集以避开观察到膈神经夺获（PNC）的区域，是否能够在不损伤膈神经的情况下实现PVI。
我们前瞻性纳入了100例连续接受大面积环状消融方法进行射频PVI的患者（年龄61.7±9.2岁，75例男性）。在右肺静脉和隆突周围进行高输出（2毫秒时20毫安）的心内膜起搏方案，此处通常会制作消融病变集。共有30%的患者发生PNC，需要修改消融线。在发生PNC的患者组中，隆突是最常见的夺获部位（85%），其次是右肺上静脉前部（RSPV）（70%）和右肺下静脉前部（RIPV）（30%）。共有25%的PNC组患者在所有3个区域（RSPV、RIPV和隆突）均有夺获。有PNC和无PNC的两组患者的临床特征无差异。两组患者中射频PVI均未导致PNI。
在右肺静脉和隆突周围进行高输出起搏显示，30%的患者膈神经位于大面积环状消融轨迹上。修改消融线以避开这些部位可能预防射频PVI期间的膈神经损伤。
